Introduction

Medicaid and the Children’s Health Insurance Program (CHIP) finance nearly half of all births each year, including a disproportionate share of births to women of color and women living in rural areas. *^[1]

Medicaid’s foundational role in maternity care financing presents a critical opportunity to leverage the program to respond to the ongoing U.S. maternal mortality crisis, which has continued to worsen in the last 30 years, even while other peer nations have generally reduced their rates of maternal mortality.^[2]

The stakes are high: Between 2018 and 2021, the maternal mortality rate increased significantly for all women.^[3]  Black women, regardless of income or education level, remain the group most likely to die or experience severe complications related to pregnancy.^[4]

The Supreme Court’s June 2022 Dobbs v. Jackson Women’s Health Organization decision, which allows states to restrict access to abortion, adds to the risks facing women and children and stands to only exacerbate geographic disparities in maternal health outcomes.^[5]  Research suggests that restricting access to abortion care could increase maternal death rates and further exacerbate current racial, economic and social inequities in maternal and infant health.^[6] Women and infants who live in many of the 24 states that have banned or are likely to ban abortion in the wake of the Dobbs decision were already at greater risk of maternal and infant mortality.  Women and children in these states are more likely to be uninsured and more likely to live in poverty than those in states with greater access to abortion care.^[7]

Medicaid policy changes have the potential to stem some of these inequities for the nearly two million mother-baby pairs covered each year.^[8] The new state option to extend pregnancy coverage from 60 days to 12 months postpartum offers a new window of opportunity to take a broader look at ways states can leverage the reach of Medicaid and CHIP financing to catalyze improvements in maternal and infant health outcomes.^[9] The bipartisan momentum to lengthen the Medicaid postpartum coverage period continues to build in state 2023 legislative sessions, and 38 states and Washington, D.C. have so far extended the postpartum coverage period.^[10]

Providing a year of postpartum coverage is an essential first step to giving new mothers ongoing access to care and helping them manage chronic conditions exacerbated by pregnancy, such as diabetes or depression, along with any other health care needs that arise during this family transition period. Federal estimates found that if all states were to elect the 12-month postpartum extension, about 720,000 more postpartum people each year will newly gain 12 months of uninterrupted coverage after the end of pregnancy, instead of the previous 60-day postpartum cutoff.^[11]

While promising, a longer coverage period does not itself lead to improved outcomes. States should take a closer look at the benefit and payment levers available in Medicaid to ensure that the longer coverage period translates to better access to needed care for mothers and infants in the postpartum year. Implementing the postpartum extension also offers an opportunity to take a fresh look at perinatal Medicaid benefits and update allowable services or providers to match the evolving research base.^[12] States can also leverage Medicaid quality improvement opportunities to target maternal health metrics, and require transparency and accountability for maternal health data and outcomes in Medicaid managed care contracts.

Benefits

States are moving to adopt new benefits and expand provider types to meet unique perinatal needs in Medicaid. The categories below are not exhaustive but offer ideas on new trends and benefit considerations in states.

Doula Care

Policymakers are increasingly looking to expand access to care provided by doulas, who are non-medical professionals that provide emotional, physical, and informational support during the prenatal, birth, and postpartum periods.^[13] Research shows that when pregnant Medicaid beneficiaries receive support from a doula throughout the perinatal period, they are less likely to experience birth complications, such as preterm birth or cesarean delivery, and less likely to experience postpartum depression and anxiety.^[14] These lower rates of complications amount to savings for state Medicaid programs: a national study showed that women who received doula support had lower preterm and cesarean birth rates than similar Medicaid beneficiaries regionally, and that doula support reduced Medicaid costs by about $986 per birth.^[15]

Community-based doula programs can be particularly effective in reducing poor birth outcomes for pregnant individuals living in underserved communities: a study of Uzazi Village, a Black-led doula program in Kansas City, Mo., found that their clients, at least 90% of whom were Black women, had significantly lower rates of premature births and babies delivered at low birth weight, than other Black women in Kansas City.^[16] An expert panel convened by the Health Research and Services Administration (HRSA) to review the agency’s community-based doula programs, which operated across the country and primarily served low-income Black and Hispanic women, found that pregnant women served by doulas who come from their same community had significant improvements in breastfeeding rates that persisted months after birth, and reduced c-section rates.^[17]

The federal Centers for Medicare and Medicaid Services (CMS) recently highlighted doula care as a “person-centered care model” of perinatal support that states could consider adopting as they implement postpartum coverage for one year after the end of pregnancy.^[18] States that have been most successful adding doula care as a Medicaid benefit have centered doulas in policymaking from the beginning of the process to avoid creating unintended barriers to doula participation, such as complex administrative requirements, and setting sustainable reimbursement rates.^[19]

Postpartum Depression Screening/Treatment

One of the key drivers of the maternal mortality crisis is untreated perinatal mood and anxiety disorders.^[20] In 2019, mothers with Medicaid or Children’s Health Insurance Program (CHIP) coverage had about twice the rate of moderate or severe anxiety (21.0 percent) compared with mothers with employer-sponsored health insurance (10.5 percent), and the rate of moderate or severe depression among mothers with Medicaid/CHIP was more than three times higher than that for mothers with employer-sponsored health insurance (8.1 versus 2.5 percent).^[21] Maternal mortality data analyzed by the Centers for Disease Control and Prevention reveals that mental health conditions are among the most common underlying causes of maternal death, and the leading underlying cause of maternal death for American Indian/Alaska Native people, Hispanic people and non-Hispanic White people.^[22]

In addition, a growing body of research links untreated maternal depression and anxiety with adverse child development and delays that can extend into adolescence, including social-emotional, cognitive, motor, and other developmental delays.^[23] Untreated perinatal mental health conditions, encompassing pregnancy and the first five years of a child’s life, carry a societal burden of an estimated $14 billion in the U.S., or an average of $32,000 for every mother–child pair affected but not treated.^[24] This is a conservative estimate.

States have flexibility to decide who can provide perinatal mental health screening and treatment services and where the services can happen. For instance, at least 46 states either require, recommend, or allow pediatricians to screen new mothers for depression during frequent, routine well-child visits in the first year of a child’s life.^[25] This aligns with the American Academy of Pediatrics’ Bright Futures screening schedule, reflecting research that links parent mental health with child development.^[26] The screening also offers an additional connection point to reach postpartum parents, who may be more likely to seek care for their child than themselves in the postpartum year.^[27]

The U.S. Preventive Services Task Force recommends that clinicians provide or refer pregnant and postpartum individuals who are at increased risk of perinatal depression to counseling interventions designed to prevent perinatal depression, based on research showing benefit for people at increased risk.^[28] Preventive care models, such as the “Reach Out, Stay Strong, Essentials for mothers of newborns (ROSE)” program, allows nurses, health educators and others with or without mental health expertise to provide intervention consisting of education on postpartum depression, managing the transition to motherhood, goal setting and review.^[29] States can also target maternal mental health services for increased reimbursement rates or create other incentives to increase the number of mental health care providers available to support new mothers in the perinatal period.

Quality Improvement

States have multiple avenues to use quality improvement, data transparency and alternative payment methodologies to drive accountability for maternal health outcomes in Medicaid. These examples are not exhaustive, but reflect the range of opportunities to use Medicaid’s outsized role in maternity care financing to make improvements in maternal health.

Require Public Reporting of Quality Metrics to Promote Accountability for Maternal Health Outcomes

As the nation faces an ongoing maternal mortality crisis that disproportionately affects Black women, clear data is essential to understanding specific challenges and areas where states must improve.^[30] CMS has created a Maternity Core Set for Medicaid and CHIP, composed of child and adult health care quality metrics that track perinatal health care, including timeliness of prenatal care, postpartum visits, and access to contraception for teens and adults.^[31]

Several of these maternity care metrics–including timeliness of prenatal care, rates of low-risk cesarean deliveries and contraceptive care– will become mandatory for states to report in 2024, as they are part of the Child Core Set which Congress required states to report by that year.^[32] This new requirement offers an important opportunity for states to set benchmarks and use the metrics to track their progress and compare themselves to their neighboring states and the national average.

In the 40 states and Washington, D.C. using contracts with Managed Care Organizations (MCOs) to deliver Medicaid benefits, states can also go beyond the federal requirements and publicly report plan-level data on maternity care performance metrics on a public website. For example, Louisiana’s Medicaid Managed Care Quality Dashboard includes plan-level data on the rates of prenatal and postpartum visits over time, among dozens of other Medicaid and CHIP quality indicators.^[33] This type of transparency is rare, but critical: it allows Medicaid stakeholders, including beneficiaries, providers, and competitor MCOs, to understand how individual MCOs are performing, and promotes MCO accountability for maternal health outcomes.^[34]

In its guidance to states on implementing the extended postpartum coverage option, CMS encouraged states to measure utilization and quality of care for postpartum people and disaggregate the data in these metrics by race, ethnicity, geography, and other indicators to help identify disparities and take targeted steps to improve maternal health equity.^[35]

Leverage Medicaid Managed Care Contracts to Improve Maternal Health Outcomes

As of August 2022, nearly two million people were enrolled in Medicaid pregnancy coverage, and the vast majority received their care delivered through MCOs.^[36]  How well the MCO performs its contract obligations determines how well Medicaid works for its beneficiaries, including pregnant and postpartum women.

State Medicaid agencies funnel billions of taxpayer dollars through MCO contracts to ensure beneficiaries can receive the timely care they need from trained providers within a reasonable distance from their homes. Depending on how states write these contracts, they can also incentivize MCOs to create access to certain types of providers, and require MCOs to set up payment arrangements that reward providers who deliver high-quality care and make improvements over time.

States lengthening the postpartum period to a year after the end of pregnancy should leverage Medicaid managed care contracts to build strong networks of perinatal health care providers to support the range of health care needs facing new mothers in the postpartum year. This could include community-based providers who can serve as trusted partners in navigating the health care landscape, such as doulas, peer support specialists, or community health workers, as well as a broader base of mental health care providers qualified to treat or prevent perinatal mental health disorders.

As an example, states could require MCOs to contract with a certain number of doulas based on the number of pregnant and postpartum mothers enrolled in the MCO, similar to a strategy used by Michigan to build out networks of community health workers.^[37] In addition, Michigan pays a higher reimbursement rate if the community health worker is employed by a community-based organization or clinic that is located closer to families, rather than a community health worker who is employed by the MCO directly. States could set similar requirements to require plans to contract with community-based doulas, lactation consultants, maternal mental health specialists or other important perinatal health care providers.

Payment arrangements can also be written into MCO contracts to include bonuses or withhold payments based on whether an MCO meets maternal health quality metric targets or reduces racial disparities in maternal health metric performance. For instance, as part of Pennsylvania’s 2022 MCO contract, plans are eligible for bonus payments based on meeting the 75^th or 90^th percentile benchmark for quality metrics for prenatal care visits, postpartum care visits, and well child visits in the first 15 months of life.^[38] Wisconsin’s 2023 Medicaid managed care contract requires all plans to conduct a performance improvement project to identify and reduce health care disparities, including narrowing disparities in postpartum care.^[39]

Conclusion

The U.S. is facing a worsening maternal mortality crisis that disproportionately affects pregnant people of color. Research suggests that the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, which overturned the constitutional protection of access to safe and legal abortions, could further exacerbate current racial, economic, and social inequities in maternal and infant health.^[40]

Because of its outsized role in financing maternity care, particularly for pregnant people of color who are at greatest risk of maternal mortality, policymakers are leveraging Medicaid to make improvements in maternal health outcomes. More than 30 states and Washington, D.C. have elected to cover one year of postpartum Medicaid, and many are adding evidence-based models of care, such as doula care and home visiting, to their benefit packages.

Requiring transparency for maternal health data in Medicaid and leveraging managed care contracts to improve maternal health outcomes are other important strategies states can use to make meaningful improvements in health outcomes and reduce racial health disparities. Advocates, care providers, community members, and state agency officials should work together to harness the power of Medicaid and CHIP to better support perinatal health care and create a stronger foundation for all families.

Editor’s note: To maintain accuracy, Georgetown CCF uses the term “women” when referencing statute, regulations, research, or other data sources that use the term “women” to define or count people who are pregnant or give birth. Where possible, we use more inclusive terms in recognition that not all individuals who become pregnant and give birth identify as women.

[1]Medicaid and CHIP Payment and Access Commission, “Medicaid’s Role in Financing Maternity Care,” (January 2020), available at https://www.macpac.gov/wp-content/uploads/2020/01/Medicaid%E2%80%99s-Role-in-Financing-Maternity-Care.pdf

[2] M. Gunja, et al., “The U.S. Maternal Mortality Crisis Continues to Worsen: An International Comparison” (The Commonwealth Fund, December 2020), available at https://www.commonwealthfund.org/blog/2022/us-maternal-mortality-crisis-continues-worsen-international-comparison

[3] DL Hoyert,  “Maternal mortality rates in the United States, 2021.” (NCHS Health E-Stats, 2023), available at https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm

[4] Op. cit. (3)

[5] Clark, M., “Biden Administration Releases Badly Needed Maternal Mortality Strategy as Dobbs Decision Could Worsen Crisis” (Georgetown University Center for Children and Families, June 30, 2022), available at https://ccf.georgetown.edu/2022/06/30/maternal-mortality-crisis-black-women-dobbs-decision/.

[6] E. Declercq, et al. “The U.S. Maternal Health Divide: The Limited Maternal Health Services and Worse Outcomes of States Proposing New Abortion Restrictions,” (The Commonwealth Fund, December 2022), available at https://www.commonwealthfund.org/publications/issue-briefs/2022/dec/us-maternal-health-divide-limited-services-worse-outcomes.

[7] I. Guarnieri and E. Nash, “Six Months Post-Roe, 24 US States Have Banned Abortion or Are Likely to Do So: A Roundup” (Guttmacher Institute, January 2023), available at https://www.guttmacher.org/2023/01/six-months-post-roe-24-us-states-have-banned-abortion-or-are-likely-do-so-roundup; E. Badger et al., “States with Abortion Bans Are Among Least Supportive for Mothers and Children” (The New York Times, July 2022), available at https://www.nytimes.com/2022/07/28/upshot/abortion-bans-states-social-services.html

[8] Johnson, K. “Missing Babies: Best Practices for Ensuring Continuous Enrollment in Medicaid and Access to EPSDT” (Johnson Group Consulting, Inc., January, 2021), available at https://ccf.georgetown.edu/wp-content/uploads/2021/03/missing_babies_EPSDT_Medicaid_finalJan2021_Johnson_edit061621.pdf.

[9] Centers for Medicare and Medicaid Services (CMS) “Medicaid and CHIP and the COVID-19 Public Health Emergency: Preliminary Medicaid CHIP Data Snapshot” (Centers for Medicare and Medicaid Services, July 2022), available at https://www.medicaid.gov/state-resource-center/downloads/covid-19-medicaid-data-snapshot-07312022.pdf.

[10] Kaiser Family Foundation (KFF), “Medicaid Postpartum Coverage Extension Tracker” (Kaiser Family Foundation, March 2023), available at https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/

[11] S. Gordon, et al., “Medicaid After Pregnancy: State-Level Implications of Extending Postpartum Coverage” (Assistant Secretary for Planning and Evaluation, December 2021), available at https://aspe.hhs.gov/sites/default/files/documents/cf9a715be16234b80054f14e9c9c0d13/medicaid-postpartum-coverage-ib%20.pdf

[12] J. Bigby, et al., “Recommendations for Maternal Health and Infant Health Quality Improvement in Medicaid and the Children’s Health Insurance Program,” (Mathematica, December 18, 2020), available at https://www.medicaid.gov/medicaid/quality-of-care/downloads/mih-expert-workgroup-recommendations.pdf.

[13] National Health Law Program, “What Is A Doula?” (National Health Law Program, April 2020), available at https://healthlaw.org/wp-content/uploads/2020/04/WhatIsADoula_4.16.2020.pdf.

[14] A. Falconi, et al. “Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching.” EClinicalMedicine, 50, 101531, available at https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00261-9/fulltext.

[15] K. Kozhimannil, et al. “Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery.” Birth (Berkeley, Calif.), 43(1), 20–27, available at https://onlinelibrary.wiley.com/doi/10.1111/birt.12218.

[16] R. Hedge, et al. “The Role of Culturally Congruent Community-Based Doula Services in Improving Key Birth Outcomes in Kansas City,” (Center for Health Economics and Policy, Institute for Public Health at Washington University, November 2022), available at https://bpb-us-w2.wpmucdn.com/sites.wustl.edu/dist/1/2391/files/2022/11/Role-of-CCCD-Services-in-Improving-Key-Birth-Outcomes-in-KCMO.pdf

[17] Health Connect One, “The Perinatal Revolution,” (Health Connect One, Chicago Ill., March 2020), available at https://www.healthconnectone.org/wp-content/uploads/2020/03/The-Perinatal-Revolution-CBD-Study.pdf

[18] Center for Medicaid and CHIP Services, “Improving Maternal Health and Extending Postpartum Coverage in Medicaid and the Children’s Health Insurance Program (CHIP),” (December, 7, 2021), available at https://www.medicaid.gov/federal-policy-guidance/downloads/sho21007.pdf.

[19] T. Guarnizo and M. Clark, “Lessons Learned from Early State Experiences Using Medicaid to Expand Access to Doula Care,” (Georgetown University Center for Children and Families, December 2021), available at https://ccf.georgetown.edu/2021/12/15/lessons-learned-from-early-state-experiences-using-medicaid-to-expand-access-to-doula-care/.

[20] J. Beauregard, et al., “Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019” (Centers for Disease Control and Prevention, September 2022), available at https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html#table4

[21] J. Haley, et al., “Mothers’ Mental Health Challenges Predated the COVID-19 Pandemic” (Urban Institute, January 2023), available at https://www.urban.org/sites/default/files/2023-01/Mothers%20Mental%20Health%20Challenges%20Predated%20the%20Covid-19%20Pandemic.pdf#page=6

[22] Op. cit. (20)

[23] A. Rogers, et al., “Association Between Maternal Perinatal Depression and Anxiety and Child and Adolescent Development: A Meta-analysis,” JAMA Pediatrics 2020;174(11):1082-1092, available at https://jamanetwork.com/journals/jamapediatrics/fullarticle/2770120.

[24] Mathematica, “Study Uncovers the Heavy Financial Toll of Untreated Maternal Mental Health Conditions,” (April 19, 2019), available at https://www.mathematica.org/news/new-study-uncovers-the-heavy-financial-toll-of-untreated-maternal-mental-health-conditions.

[25] National Academy for State Health Policy, "Medicaid Policies for Caregiver and Maternal Depression Screening During Well-Child Visit, By State," (National Academy for State Health Policy, March 2023), available at https://nashp.org/maternal-depression-screening/

[26] American Academy of Pediatrics (AAP), “Bright Futures Toolkit: Links to Commonly Used Screening Instruments and Tools” (American Academy of Pediatrics, November 2022), available at https://publications.aap.org/toolkits/resources/15625/?autologincheck=redirected

[27] J. Lines, “One Appointment, Multiple Healthier Outcomes: Screening Moms at Well-Baby Visits,” (Penn Medicine News, February 2018), available at https://www.pennmedicine.org/news/news-blog/2018/february/one-appointment-multiple-healthier-outcomes-screening-moms-at-well-baby-visits

[28] U.S. Preventative Services Task Force, “Final Recommendation Statement: Perinatal Depression: Preventive Interventions,” (February 12, 2019), available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/perinatal-depression-preventive-interventions.

[29] E. O’Connor, et al., “Interventions to Prevent Perinatal Depression: A Systematic Evidence Review for the U.S. Preventive Services Task Force,” (Agency for Healthcare Research and Quality, February 2019), (Evidence Synthesis, No. 172.), available at https://www.ncbi.nlm.nih.gov/books/NBK537819/.

[30] Centers for Disease Control and Prevention (CDC), “Four in 5 Pregnancy-Related Deaths in the U.S. Are Preventable” (Centers for Disease Control and Prevention, September 2022), available at https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html

[31] Centers for Medicare and Medicaid Services (CMS), “Quality of Maternal and Perinatal Health Care in Medicaid and CHIP: Findings from the 2020 Maternity Core Set” (Centers for Medicare and Medicaid Services, November 2021), available at https://www.medicaid.gov/medicaid/quality-of-care/downloads/2021-maternity-chart-pack.pdf

[32] M. Clark, “Proposed Rule Offers Opportunity to Help Advance Maternal Health Equity” (Georgetown University Center for Children and Families, October 2022), available at https://ccf.georgetown.edu/2022/10/11/proposed-rule-offers-opportunity-to-help-advance-maternal-health-equity/

[33] Louisiana Department of Health, “Louisiana Medicaid Managed Care Quality Dashboard,” available at https://qualitydashboard.ldh.la.gov/.

[34] A. Corcoran, et al., “Transparency in Medicaid Managed Care: Findings from a 13-State Scan,” (Georgetown University Center for Children and Families, September 2021), available at https://ccf.georgetown.edu/wp-content/uploads/2021/09/MCO-13-state-scan-v3.pdf.

[35] Op. cit. (19)

[36]Op. cit. (34)

[37] State of Michigan, Central Procurement Services, "Contract Change Notice," (September 20, 2021), available at https://www.michigan.gov/.

[38] State of Pennsylvania, Department of Human Services, “2022 Community HealthChoices Agreement,” (January 2022), available at https://www.dhs.pa.gov/HealthChoices/HC-Services/Documents/HC%20Agreement%202021.pdf.

[39] Wisconsin Department of Health, Forward Health Contracts, “Badger Care Plus and Medicaid SSI: 2022-2023 HMO Contract,” (January 2023), available at https://www.forwardhealth.wi.gov/WIPortal/content/Managed%20Care%20Organization/Contracts/Home.htm.spage.

[40] C. Daniel, et al., “State Abortion Policies and Maternal Death in the United States, 2015-2018” (National Institutes of Health, August 2019), available at https://pubmed.ncbi.nlm.nih.gov/34410825/; M. Aswani et al., “Racial/Ethnic and Educational Inequities in Restrictive Abortion Policy Variation and Adverse Birth Outcomes in the United States” (BMC Health Services Research, October 2021), available at https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-07165-x